Every finding on record at Home Care With A Heart Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 11/14/23, 11/15/23. and 11/16/23 Active Census: 6 At this Emergency Preparedness survey, Home Care With A Heart was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR complete by Area 3 on 11/28/2023.

This visit was for a Federal Recertification and State Re-licensure Survey of a Medicaid Home Health Provider conducted by the Indiana Department of Health. Survey Dates: 11/14/2023, 11/15/2023, and 11/16/2023. Facility ID: 23-002640-1 Provider #: 15k009 Medicaid #: 200305630 12 Month Unduplicated Skilled Admissions: 0 The administrator was notified of a partially extended survey on 11/14/2023 at 2:50 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC. QR completed by Area 3 on 11/28/2023.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to track, trend and measure Quality Assurance Performance Improvement (QAPI) data collected to monitor the safe and quality care for patients and staff for 1 of 1 QAPI programs. Findings include: 1. Review of an agency policy on 11/16/2023, titled “Home Care with a Heart Inc. Quality Assessment Improvement Plan Policy and Procedure.” stated, “ … Home Care with a Heart Inc. will strive to improve operational and client health outcomes by implementing a performance improvement plan that incorporates the following essential processes; designing processes, monitoring performance through data collection, analyzing current performance and improving and sustaining improved performance over time ... ” 2. Review of the agency QAPI program on 11/16/2023, evidenced an agency document titled “Quality Data 2023”, the agency had percentages next to data of care plans, supervisory notes, etc…were followed in January, April, July, and October. Review failed to evidence the agency analyzed and tracked incidences such as falls and infections agency wide. 3. During an interview on 11/16/2023, at 2:04 PM, the administrator indicated the agency tracked falls and infections but indicated nothing was documented. 17-12-2(a)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure infection control practices were upheld according to the agency’s policy in 1 of 3 home visits for personal protective equipment (PPE) requirements and indications for use in patient care, pertaining to gloving. (Patient: #4) 1. A review of a Home Care with a Heart policy was provided by the Administrator, on 11-16-2023 at 4:02 PM. The “Glove Technique-Clean” indicated but was not limited to, “ … 2. Don clean gloves whenever you may come into contact with Blood, urine, Sputum, or feces … ” 2. During a home visit at Patient #4’s residence on 11/15/2023 at 9:12 AM, the Home Health Aide (HHA) HHA 2, was observed giving a bath and cleaning perineal area and rectal area prior to donning new gloves before placing gloved hand on patient #4’s hand to help them stand up to go to bed. HHA 2 failed to change gloves after coming into contact with bodily fluids. 3. During an interview on 11/16/2023 at 3:55 PM, the Administrator confirmed that gloves were to be changed before helping patient back to bed. 410 IAC 17-12-1

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation and interview the Administrator or predesignated person failed to be available during hours of operation for 2 hours and 15 minutes during business hours for 1 of 3 survey days. Findings include: 7. On 11/14/23 at 11:46 AM a phone call was placed to the number listed as available 24 hours a day on the Agency’s office door. The phone call went to voice mail and a message was left identifying the caller and the purpose of the call. 8. On 11/14/23 at 12:34 PM the Administrator phoned and reported having the phone on vibrate, not hearing the calls, and had missed the calls. 9. On 11/14/23 at 1:09 PM the Administrator arrived at the agency. 1. On 11/14/23 at 10: 16 AM observed entrance to the Agency to be locked and all lights off. A sign posted on the door dated 3/19/2020 stated, “Due to the COVID-19 virus our office will be maintaining flexible hours. There is always a nurse on call who can be reached at [phone number of agency].” 2. Information received by the Indiana Department of Health updated 07/12/2023 indicated the Agency’s “OPERATING HOURS” are Monday through Friday from 9:00 AM until 2:00 PM. 3. On 11/14/23 at 10:19 AM a phone call was placed to the number listed on the agencies door as available 24 hours a day. No answer, surveyor left voicemail with callback number and purpose for call. 4. On 11/14/23 at 10:48 AM, phone call was placed again to number on door. No answer, surveyor left another voicemail with call back number and purpose for call. 5. On 11/14/23 at 11:00 AM, left 1220 West Main Street to go check a previous address for the agency at 104 Granby to see if staff available. No building listed as Home Care with a Heart. 6. On 11/14/23 at 11:45 AM, arrived back at 1220 West Main Street agency, went to knock on door again, check status if administrator had come back to facility, no answer at facility door.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to provide skilled nursing services for 1 of 1 home health agency for 45 weeks of 53 weeks in 2023. Findings include: 1. During the entrance conference on 11/14/23 at 1:22 PM, the Administrator reported the agency currently has patients receiving home health aide services and/or attendant care service and they no longer offered skilled nursing services as the Agency is closing with an undetermined date of closure. 2. A review of the Agency’s active patient list received from the administrator on 11/14/2023 at 1:45 PM evidenced 6 active patients. The list evidenced 4 Patients receiving home health aide services with attendant care services and 2 Patients receiving attendant care services. No patients were listed as receiving any skilled services. 3. A review of the agency’s discharge list evidenced one patient was receiving Skilled Nursing visits and was discharged on December 31st, 2022. (Patient #5) 4. A review of a physician’s order for Patient # 5 dated 12/31/22 no time indicated, evidenced an order to discharge the patient from skilled services. 5. During an interview with the Administrator on 11/14/23 at 3:17 PM, they reported the agency was closing and had discharged all skilled patients with the last discharge on December 31st, 2022, and had not admitted or planned to admit any skilled patients.